Does lymphadenectomy add anything to the treatment of esophageal cancer?
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Adenocarcinoma↗
Biomedical subjects
S Law
Publications and source records attributed to S Law.
A neuropsychological analysis of schizophrenic thought disorder.
We examined the relationship of schizophrenic thought disorder, as measured by the Thought Disorder Index (TDI), with (1) neuropsychological measures of verbal memory, abstraction, executive function, visual memory, and working memory; and (2) quantitative MRI measures of prefrontal and basal ganglia structures. TDI scores correlated strongly with tests of verbal memory, abstraction and executive functions, modestly with tests of working memory, but did not correlate with scores on tests of visual memory. Neither TDI scores nor their neuropsychological correlates were associated with frontal or basal ganglia magnetic resonance imaging (MRI) measures, with the exception of the measures of working memory that demonstrated a modest relationship with frontal and basal ganglia structures. These findings suggest that schizophrenic thought disorder may be strongly related to neuropsychological impairments in verbal memory, abstraction and executive functions, and modestly related to problems with working memory in this sample of patients.
Adult↗
The significance of histologically infiltrated resection margin after esophagectomy for esophageal cancer.
BACKGROUND: Microscopic tumor infiltration of the resection margin after esophageal resection is implicated to influence anastomotic leakage, tumor recurrence rates, and long-term survival. METHODS: Patients with tumor infiltration of resection margin (RM+) and those without (RM-) were compared. RESULTS: Of 604 patients, 45 (7.5%) were RM+. Patients in the RM+ group had more palliative resections, 76% versus 56%, P = 0.01. Anastomotic leakage rates were 2.2% (RM+) and 4.1% (RM-), P = 1.0. Excluding hospital deaths, anastomotic recurrences developed in 10.3% in the RM+ group and 4.9% in the RM- groups, P = 0.15. Although a positive margin did not increase anastomotic recurrence, a shorter resection margin correlated with such recurrence. The mean (SEM) lengths of resection margins in surgical specimens were 2.7 cm (0.3) and 4.4 cm (0.1) for those with and without recurrence, P < 0.001. Median survival time were 8.8 months (RM+) and 15 months (RM-), P = 0.007. CONCLUSIONS: Histologic infiltration of resection margins did not influence leakage rate. Anastomotic recurrence was related to the length of resection margin.
Adult↗
Extrahepatic biliary obstruction by metastatic gastric carcinoma.
Forty-one patients with extrahepatic biliary obstruction by metastatic gastric carcinoma underwent retrospective study to determine demographics, clinical features, laboratory findings on presentation, time interval from previous gastrectomy, level of biliary obstruction, methods of palliation, complications from treatment, treatment results, and survival. Thirty-seven patients underwent biliary decompression by percutaneous transhepatic biliary drainage (PTBD) (35 patients), endoscopic insertion of plastic stent (one patient), and operative insertion of T tube (1 patient). The remaining 4 patients had no biliary drainage procedure performed. Subsequently expandable metallic biliary stents were inserted in 9 patients through the PTBD tract. Two patients received postdrainage external irradiation. Reduction in serum total bilirubin was seen in all patients after drainage. Two patients were alive at the time of this analysis. The median survival of these 41 patients was only 70 days. The 6- and 9-month survival rates were 27.0% and 9.7%, respectively. Hemoglobin (p < 0.001) and total bilirubin (p < 0.002) on presentation were found to be independent factors predicting survival. Extrahepatic biliary obstruction by metastatic gastric carcinoma was associated with poor survival. Patients with profound anemia or jaundice on presentation carried the worst prognosis.
Adenocarcinoma↗
Word recall in schizophrenia: a connectionist model.
OBJECTIVE: The authors examined word recall of patients with schizophrenia by using an experimental paradigm generated from connectionist models of memory. METHOD: Schizophrenic patients and normal comparison subjects first studied and then recalled a list of 32 words of equal difficulty. Both the connectivity (associative strength) and the network size (number of associates) of the words varied in such a way that the list contained equal proportions of four types of words: 1) high connectivity-small network size, 2) low connectivity-small network size, 3) high connectivity-large network size, and 4) low connectivity-large network size. RESULTS: The schizophrenic patients recalled fewer words and showed a particularly pronounced effect of the connectivity of the to-be-remembered words. For the patients, regardless of network size, recall improved substantially for words of high connectivity and declined dramatically for words of low connectivity. By contrast, the comparison subjects showed the expected effects, with the best recall for words of high connectivity-small network size, followed by words of low connectivity-small network size, then by words of high connectivity-large network size, and finally by words of low connectivity-large network size. CONCLUSIONS: Schizophrenia may be characterized by faulty modulation of associative links within a putative lexicon that is thought to be widely distributed across frontal and temporal lobes.
Adult↗
The value of neck drain in esophageal surgery: a randomized trial.
The use of surgical drains in certain clean elective operations remains controversial. To evaluate the role of closed-suction drain for an esophageal anastomosis in the neck, we conducted a randomized, controlled study in 40 patients with esophageal carcinoma who underwent esophagectomy with an esophageal anastomosis in the neck, half of whom had a neck drain inserted at the end of operation. The median (range) duration of drainage was 46 hours (36 to 88 hours). The median (range) amount of drainage was 63 ml (15 to 210 ml). There was no incidence of haematoma or seroma formation in both the drained and non-drained groups. Anastomotic leakage did not occur in any patient. The benefits of closed suction neck drain could not be demonstrated. Routine use of neck drain for esophageal anastomosis in the neck is not necessary.
Aged↗
Prevalence and predictive value of p53 mutation in patients with oesophageal squamous cell carcinomas: a prospective clinico-pathological study and survival analysis of 70 patients.
The tissues from 70 Chinese patients with oesophageal squamous cell carcinoma were prospectively collected to study for the pattern of p53 mutations and its relationship with clinico-pathological features and prognosis using immunohistochemistry, polymerase chain reaction-single strand conformational polymorphism (PCR-SSCP) analysis and DNA sequencing. p53 over-expression and p53 mutations were detected in 73% and 44% of the patients. These p53 aberrations had no relationship with the patient age, sex, smoking/drinking habits and tumor site, size or stage. The p53 over-expression was more intense in moderately/poorly-differentiated squamous cell carcinomas. Thirty-three p53 mutations were noted in 31 patients; 18.2% in exon 5, 15.2% in exon 6, 33.3% in exon 7 and 33.3% in exon 8. Mutations were primarily point mutations and common in codons 248, 273 and 285. There were 46% transversions, 36% transitions and 18% frameshift. The survival of the patients depended mainly on the extent of resection. In patients with stage III oesophageal cancer, the median survival of those with p53 mutations was 6.8 months whereas those without was 12.5 months. The results were of clinical importance although the value did not reach statistical significance. Thus, there was a definite role of p53 mutations in the pathogenesis of oesophageal squamous cell carcinomas. p53 mutations were not synonymous with p53 over-expression. The distribution of p53 mutations in oesophageal cancers suggested that the etiologic contribution might be complex and probably involve different exogenous and endogenous exposures. p53 mutations also appear to play a role in predicting the survival of patients with stage III oesophageal squamous cell carcinomas.
Adult↗
Prospective evaluation of vacuum pleural drainage after thoracotomy in patients with esophageal carcinoma.
OBJECTIVE: To evaluate the safety and efficacy of vacuum pleural drainage systems in selected patients. DESIGN: Prospective nonrandomized study. SETTING: Division of Upper Gastrointestinal Surgery at a tertiary care center. PATIENTS AND INTERVENTION: Between January 1, 1995, and December 31, 1995, 32 patients underwent a right-sided posterolateral thoracotomy for the resection of esophageal carcinoma. A vacuum drain was employed in 21 patients (group 1) and an under-water drain in 11 patients (group 2). The selection of patients for vacuum drainage was based on minimal pleural adhesions and technical ease of the operation. MAIN OUTCOME MEASURE: Data on drainage efficiency, total drainage output and duration of the drain being left in situ, and postoperative pulmonary complications were analyzed. RESULTS: The median total drainage outputs were 1280 mL and 1230 mL (P = .92, Mann-Whitney U test) in groups 1 and 2, respectively, and the median duration of chest drains being left in situ was 7 days and 6 days (P = .11, Mann-Whitney U test) in groups 1 and 2, respectively. Postoperative pulmonary complications occurred in 5 patients (24%) enrolled in group 1 and 5 patients (45%) enrolled in group 2 (P = .09, Fisher exact test). No hospital mortality was reported during the study. CONCLUSION: The vacuum drain has proved to be as safe and efficient as the traditional underwater drain, imposing less discomfort and allowing early mobilization. The vacuum drain is, therefore, recommended in selected patients undergoing thoracotomy for esophageal resection.
Drainage↗
Postoperative analgesia reduces mortality and morbidity after esophagectomy.
BACKGROUND: To study the influence of postoperative analgesia on morbidity and mortality after esophagectomy. METHODS: The outcomes of 578 patients who underwent one-stage resection between 1986 and 1995 were analyzed. Patients who received either epidural morphine, patient-controlled analgesia, or continuous intravenous morphine infusion supervised by an anesthesiology-based acute pain service (group APS, n = 299) were compared with those for whom conventional intramuscular meperidine injections were used (group CON, n = 279). RESULTS: For patients who underwent transthoracic esophagectomy, group APS (n = 226) had a lower incidence of pulmonary complications (13% versus 25%, P = 0.002), cardiovascular complications (21% versus 43%, P < 0.001), and hospital mortality (8% versus 14%, P = 0.038) when compared with group CON (n = 189). No similar difference was demonstrated in patients who underwent esophagectomy without thoracotomy. The hospital stay (days) was shorter in group APS than in group CON for both transthoracic esophagectomy (22 +/- 20 versus 30 +/- 37, P = 0.005) and nontransthoracic esophagectomy patients (19 +/- 13 versus 25 +/- 21, P = 0.029). CONCLUSION: Adequate postoperative analgesia is associated with lower cardiopulmonary complications, lower mortality and reduced cost in patients undergoing transthoracic esophagectomy.
Analgesia↗
Preoperative chemotherapy versus surgical therapy alone for squamous cell carcinoma of the esophagus: a prospective randomized trial.
OBJECTIVE: This study investigated the role of preoperative chemotherapy in squamous cell cancer of the esophagus. METHODS: A prospective randomized trial was undertaken in 147 patients: 74 received preoperative chemotherapy comprising cisplatin and 5-fluorouracil and 73 had surgical therapy alone. End points were cancer and therapy-related deaths. RESULTS: Sixty-six patients (89%) in the chemotherapy group underwent resection compared with 69 (95%) in the control group (p = not significant). Of the 60 patients who had resection after completing the chemotherapy program, 35 (58%) had a significant response, of whom four (6.7%) had a complete pathologic response. Postoperative mortality rates were 8.3% and 8.7% in the chemotherapy and control groups, respectively (p = not significant). Significant downstaging was evident with chemotherapy; curative resections were possible in 67% of these patients compared with 35% in the control group (p = 0.0003). T3 and T4 tumors were found in 67% and 91% of the chemotherapy and control groups, respectively (p = 0.0002). The respective figures for N1 disease were 70% and 88% (p = 0.009). An intent-to-treat analysis of survival showed no significant difference between the two groups. Median survivals were 16.8 and 13 months, respectively (p = 0.17). Of those who completed the chemotherapy and resection, responders fared better than control patients. Median survivals were 42.2 months and 13.8 months, respectively (p = 0.003). Median survival (8.3 months) was worse for nonresponders than for control patients (p = 0.03). The recurrence pattern suggested a significant reduction in locoregional disease with chemotherapy. CONCLUSIONS: Preoperative chemotherapy was safe and resulted in significant downstaging and an increased likelihood of curative resection. Survival was not better than that in the surgery-alone group, but responders did fare better than nonresponders.
Aged↗
Thoracoscopic esophagectomy for esophageal cancer.
BACKGROUND: Minimal access surgery is an alternative to open surgery in esophageal surgery. Its role in cancer resection is controversial. METHODS: Thoracoscopic esophageal resection was attempted in 22 patients who had increased operative risk. Postoperative outcomes of these patients were compared with the outcomes of 63 patients who underwent open thoracotomy resection during the same period. RESULTS: Thoracoscopy was completed in 18 patients. Conversion to thoracotomy was necessary because of locally advanced tumor in three patients, and a bypass procedure was performed in another patient because of poor ventilation during thoracoscopy and the finding of metastatic disease. The median thoracoscopy time was 110 minutes (range, 55 to 165 minutes). The total operating times were 240 minutes (range, 165 to 360 minutes) and 250 minutes (range, 190 to 420 minutes) for thoracoscopy and thoracotomy, respectively, p = 0.5. Blood loss was significantly less than that of open resection; medians were 450 ml (range, 200 to 800 ml) and 700 ml (range, 300 to 2500 ml) for thoracoscopy and thoracotomy, respectively, p < 0.01. The median number of lymph nodes removed at thoracoscopy was 7 (range, 2 to 13) compared with 13 (range, 5 to 34) in the thoracotomy group. Bronchopneumonia affected 17% of both groups of patients. Only one patient who was converted to open thoracotomy died. Port site recurrence developed in one patient. Overall survival rates were not significantly different. CONCLUSIONS: Thoracoscopic esophageal resection was a feasible option. Clear advantages over open thoracotomy were not demonstrated, although patients who were selected for thoracoscopy had worse performance status. This technique deserves further investigation in dedicated centers.
Adult↗
Pre-operative chemotherapy for squamous cell carcinoma of the oesophagus: do histological assessment and p53 overexpression predict chemo-responsiveness?
Pre-operative chemotherapy is increasingly used in the treatment of oesophageal carcinoma. However, no features have been identified which can reliably predict a positive response to chemotherapy. The aim of this study was to examine whether histological features and p53 overexpression could predict such response. Prechemotherapy endoscopic biopsies from 55 patients, who subsequently completed two courses of chemotherapy followed by surgical resection, were studied. Patients were classified into responders and non-responders according to clinical and pathological findings. Pathological features of the endoscopic biopsies examined included adequacy of the tumour tissue, histological grade, degree of keratinisation, histologic patterns, mitotic rates and nuclear pleomorphism. Biopsy specimens were also tested for p53 overexpression using p53 protein specific mouse monoclonal antibody DO-7 on paraffin sections. Histologic features and p53 expression were correlated to chemoresponsiveness. 76% (42 of 55) of patients had sufficient biopsy tissue for assessment. Response to chemotherapy was evident in 64% (n = 27) of patients. None of the non-responders had tumours with high-grade nuclear pleomorphism compared with 37% (10 of 27) of responders (P = 0.01). All patients with high-grade nuclear pleomorphism responded to chemotherapy. No significant differences were found between the responders and non-responders with respect to tumour differentiation (P = 0.7), degree of keratinisation (P = 0.3) and mitotic rates (P = 0.8). Overall, p53 overexpression was noted in 67% (28 of 42) of patients. This was more prevalent in non-responders (12/15) compared to responders (16/27), but this was not statistically significant (P = 0.08). The degree of p53 overexpression had no significant relationship with responsiveness to chemotherapy. High-grade nuclear pleomorphism, identified on pretreatment biopsy specimens, correlated with response to chemotherapy, whereas p53 overexpression did not correlate with response. Improved tissue sampling and further investigations should be done so that the assessment of prechemotherapeutic endoscopic biopsies can have significant impact on clinical decision making.
Aged↗
Penetrating oral foreign body presenting as an aural polyp.
A case of a penetrating oral foreign body presenting with an aural polyp is described. The possibility of a penetrating oral injury should be considered whenever a child's fall is unwitnessed, as it is easily overlooked. An underlying foreign body should be considered in cases where an aural polyp fails to respond to standard therapy. MRI may be the best imaging technique to identify plastic foreign material.
Accidental Falls↗
ERP assessment of visual and auditory language processing in schizophrenia.
Language disturbance in schizophrenia has been recently attributed to disturbed priming mechanisms. In the present study, event-related potentials (ERPs), were recorded to final words in sentences presented to 13 chronic patients with schizophrenia and 12 normal controls. Half of the final words fit a sentence context and another half did not. The N400 (the ERP sensitive to language) latency was prolonged, and its amplitude was more negative to both correct and incorrect sentence endings in the group with schizophrenia relative to the group of normal controls. The early ERP components, N100 and P200, were similar in both groups. These results suggest that language abnormalities in schizophrenia are related to a dysfunction in the language system and not to a general cognitive dysfunction, and may be related to poor use of context in patients with schizophrenia.
Adult↗
Comparison of hand-sewn and stapled esophagogastric anastomosis after esophageal resection for cancer: a prospective randomized controlled trial.
OBJECTIVE: The objective of this study was to compare the hand-sewn and stapled methods in esophagogastric anastomosis. SUMMARY BACKGROUND DATA: After esophageal resection for cancer, the relative merits of the hand-sewn and the stapled methods of esophagogastric anastomosis, especially regarding leakage and stricture rates, have not adequately been studied. METHODS: A prospective randomized controlled trial was undertaken in 122 patients with squamous cell cancer of the thoracic esophagus who underwent a Lewis-Tanner esophagectomy. Patients were stratified according to esophageal size, based on the diameter of the divided esophagus (< or > or = 30 mm) and then were randomized to have either a hand-sewn or a stapled anastomosis. RESULTS: The mean total operating times (standard error of the mean) when the hand-sewn and the stapled methods were used were 214 (4) minutes and 217 (3.4) minutes, respectively (p = not significant [NS]). The respective in vivo proximal resection margins (standard error of the mean) were 8 (0.4) cm and 7.6 (0.4) cm (p = NS). Leakage rates were 1.6% and 4.9% (p = NS). Excluding hospital deaths, patients with leakage or anastomotic recurrence, and those who received radiation therapy to histologically infiltrated resection margin, anastomotic stricture was found in 5 (9.1%) of 55 patients in the hand-sewn group and 20 (40%) of 50 in the stapler group (p = 0.0003). The difference in stricture rates was significant in small as well as large esophagi. Anastomotic recurrence developed in only one patient in each group. CONCLUSIONS: The authors conclude that both methods were safe, but the stapled technique resulted in more stricture formation.
Aged↗
Skin surface lipids inhibit adherence of Candida albicans to stratum corneum.
BACKGROUND: Candida albicans (CA) infections represent a significant threat to the health of immunocompromised individuals. The initial step in the establishment of a CA infection is adherence of the organism to an epithelial surface. METHODS: An in vitro model for studies on adherence of CA to keratinized surfaces has been developed and used to test the hypothesis that specific lipids can modulate adherence of this organism. Porcine stratum corneum (SC) disks were incubated with candidal suspensions, after which unattached cells were washed away. Adherent cells were stained and counted using light microscopy. RESULTS: Attachment of three pathogenic CA isolates was significantly greater than attachment of commensal strains of either CA or Candida parapsilosis. Removal of lipid from the SC lead to a doubling of the number of adherent organisms, whereas additional skin lipid inhibited adherence. Squalene, wax esters, cholesterol esters and triglycerides had no effect on adherence, but fatty acids, sterols and ceramides inhibited adherence significantly. CONCLUSIONS: Specific epithelial lipids can modulate adherence of CA to keratinized epithelial surfaces.
Animals↗
Diary of a novice Cochranite. Random thoughts on the third annual Cochrane Collaboration Colloquium.
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Computer Communication Networks↗
Pyloroplasty and pyloromyotomy in gastric replacement of the esophagus after esophagectomy: a randomized controlled trial.
BACKGROUND: Drainage methods for the gastric conduit after esophagectomy for carcinoma have been controversial. STUDY DESIGN: In a randomized controlled trial, 92 patients with esophageal carcinoma were randomized to have pyloroplasty or pyloromyotomy as a drainage procedure for the gastric conduit used for esophageal replacement. Only patients who underwent Lewis- Tanner operation or esophagogastrectomy and who had normal pyloroduodenal regions were included. RESULTS: The mean postoperative daily nasogastric output (SEM) were 164 mL (17 mL) in the pyloroplasty group and 179 mL (21 mL) in the pyloromyotomy group (p = not significant). No leakage occurred at the pyloroduodenal region in either group. In both groups, the anastomotic leakage rate was 2 percent, and the in-hospital mortality rate was 7 percent. No significant difference was found in postoperative morbidity and mortality. Gastric outlet obstruction developed in only two patients who underwent pyloromyotomy, and both required reexploration. One died of malignant obstruction of the gastric outlet and aspiration pneumonia. Scintigraphy performed 6 months after operation showed that the median half-life (interquartile range) for gastric emptying was 19 minutes (10 to 24 minutes) in the pyloromyotomy group and 8 minutes (5 to 19 minutes) in the pyloromyotomy group (p = 0.04). Long-term follow-up up to 5 years, however, did not reveal significant differences between the two groups in the type and quantity of food consumed. The incidence of other symptoms such as regurgitation, diarrhea, bile reflux, and dumping, also was no different. CONCLUSIONS: Pyloroplasty and pyloromyotomy were effective and safe drainage procedures for the gastric conduit used for esophageal replacement. The choice depends on the preference and experience of the surgeon. Most patients adapted to their new conduit with time.
Anastomosis, Surgical↗